Research Article Critique on Diabetes

 This research was carried out by 3 researchers who have experience in conducting research studies based on their level of qualification. Rona Parker is a registered nurse RN with a Masters Degree in Education and a PhD who presently work as an Assistant Dean and Associate Professor at the School of Osteopathic Medicine, University of the Incarnate Word, Texas. Her colleague Mary Jane Jones is a RN with a PhD and a Professor at the BG Lillian Dunlap Professor Emerita of Nursing at the same University in Texas. The 3^rd researcher is Linda Hook who has a Masters in Nursing, Advanced Public Health Nurse (APHN-BC), and MSHP. She works as an instructor at the IIa Faye Miller School of Nursing and Health Professions.

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 The title of the article did not explicitly state the study population but inferences can be made that it involves patients with diabetes because of the inclusion of the word glycemic control. The other stated variable is the Nurse Practitioner (NP) and the interprofessional collaborative practice team which demonstrated a correlational study. The abstract indentified the key components of the study that included the background and purpose of the study, the design including the sample, conclusion and the implications for nursing practice.

Steps in the Research Process

Problem – the problem surrounds glycemic control of patients with diabetes and the ability of the NP and interprofessional team to improve clinical outcomes. Glycemic control has been a challenge for many patients living with diabetes and contributes to several micovascular and macrovascular complications which potentially increases the risk of premature death from these complications. According to Parker et al, (2016), inorder for patients to fully benefit from the health care services and be more successful at controlling their blood sugar their care should be addressed from the point of initial care with the provider and with involvement from the interprofessional team. With this model of care facilitated by the NP, each member of the team can maximize their interventions to improve patient outcome.

Purpose– The problem was to identify differences of blood sugar control of patients at risk when treated by a NP and an interprofessional collaborative practice team inclusive of the NP within a one year period. (Parker, 2016).

Review of Literature- The authors reviewed a total of 24 articles, of which 10 were under 5 years, 9 under 10 years and 4 over 10 years, which demonstrated that these references were current in relation to the time of study. Parker et al, (2016) reviewed previous study on the improved effects that nurse /manager trained in diabetes management had on diabetes control within a short time span, but not much evidence on overall outcome. They also looked at 3 studies that mentioned the involvement of self-management. Another that dealt with improvement in glycemic control with more frequent contact from health care providers, and another that looked at the effects of involving a case manager to self- management education program. Parker et al, (2016) believes that the result of some previous studies may have been affected negatively based on the confusion of the meaning of disease management, care coordination and what is involved in collaborative intervention. It is important when looking at a study to understand the contextual meaning of certain terminologies hence the reason for inclusions of some of these terms with their definition in the study.

Study Framework

Research Question- The authors states two research questions which were:- 1) “What are the differences in glycemic control among patients with at-risk diabetes cared for by a nurse practitioner only and those who received additional follow-along care by an interprofessional team ?”(Parker et al, 2016). 2) Are there differences in pre-post glycemic control among patients with at-risk diabetes who are followed by an Interprofessional Education and Collaborative Practice (IPECP) Faculty Team for two or more visits by two of more disciplines?”(Parker et al, 2016).

Variables: At risk patients with diabetes who had HgbA1C between 7-9% (moderate) and high risk > 9%.

Design: Typically the pretest-posttest research design would include an intervention group and a control group for both pretest and post test. (Sutherland, 2017, Quantitative Methodology: Interventional Designs and Methods). But in this study the authors decided to use the pre-post design without the control group where they looked at the result of glycemic control in at-risk patients with diabetes who was either treated by the NP only and those treated by the interprofessional team at a clinic within the community. (Parker, et al, 2016). Here below is a diagrammatic representation of the research design-pre-post test without a control group.

Sample, Population and Setting:  The study included a clear documentation of the protocols that were used which were “the health center protocols for care which was in keeping with the Healthcare Effective Data and Information Set (HEDIS) 2011 guidelines and standards of medical care for diabetes patients (ADA), 2014”. Following these protocols were the laboratory testing of all patients. (Parker et al, 2016). As a mean of classifying these patients, those with HgbA1C > 7% were referred by the Family Medicine Clinic staff to the Family Nurse Practitioner (FNP) Clinical Coordinator who became their primary care provider. (Parker et al, 2016). These patients were classified as moderate risk. Also those at high risk who refused to participate in the interprofessional team. Those patients assigned to the other group  was in the high risk category with HgbA1C> 9% who were available during day shift hours and willing to participate, were treated by the interprofessional team (Parker et al, 2016). No extraneous variables were identified. The authors utilized a convenience sampling method of adult, non-pregnant patients at-risk type 2 diabetes seen in 2014, who were referred to a NP for care, and were triaged for interprofessional team for follow-along care who volunteered (Parker, et al, 2016).

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The study occurred in a natural setting, (Grove, 2017, Sampling). A Federally qualified and funded health center (FQHC) and a Liberal Arts University in Texas, which was appropriate for the study. The research was conducted in a clinic that was in close proximity to a large center that mostly cater to patients of low-income status with a high incidence of diabetes, (Parker et al, 2016). No exclusion were explicitly stated but based on the patients that were included it can be deduce that patients with HgbA1C < 7%, and those who were pregnant and were seen before 2014 (Parker et al, 2016), were excluded.

Protection of human study: The author got approval from the university Institutional Review Board for the Protection of Human Subjects before funding was granted or the project started. In the study mention was made that the participants signed a consent form but it gave no details if the participants were informed of the details of the study. According to Gray (2017, Ethics in Research), “voluntary consent is obtained after the prospective subject has been given essential information about the study and has shown comprehension of this information, FDA, 2010”. Also “the prospective subject has decided to take part in the study of his or her own volition without coercion or any other influence.” (Gray, 2017, pp 157-188).

Data Collection: data from the Electronic Medical Record were collected using the FNP discrete provider number from all patients seen at the end of the calendar year. These records were de-identified into an Excel Spreadsheet for analysis by the Information Technology staff of the FQHC (Parker, et al 2016). Data from patient encounter with the IPECP Faculty Team were collected. “Each team patient was assigned a project identification number at the time of consent. These data were recorded weekly by members of the IPECP team on each patient on the team-designed data collection sheet.” (Parker et al, 2016), and de-identified data by project identification number by the IPECP team evaluator. “The data were linked electronically with the FNP data from the Electronic Medical Record.” (Parker, et al, 2016).

Data Analysis: The authors used the Excel Spreadsheet to link the two databases where the results were transferred to the SPSS version 19 for analysis. Due to the pre-post study design they utilized the paired t-test to analyze results which is reliable because it was designed to measure results after an intervention. The data from the patients were retrieved from the Electronic Medical Record and from data from the encounter with the IPECP team but the article did not explicitly state when and by whom the original data were collected.

Interpretation of Findings: With regard to the first research question, “of the 86 patients who had two or more visits by the FNP, only 45 had pre-post data on HgbA1C. There were no significant differences in mean HgbA1C level only.”(Parker et al, 2016). On the other hand in relation to the second question, “of the 34 patients with two or more clinic visits with the FNP then followed up by IPECP team for at least one visit, 32 had pre-post data on HgbA1C.” (Parker et al, 2016). Therefore there was a statistically significant decrease in HgbA1C after the team approach was initiated.

Evaluation of the Study: According to Parker et al, (2016), the findings of the study are said to be in keeping with results of previous studies that examined changes in HgbA1C results when cared for from a coordinated team effort. The authors did not explicitly state whether the findings are easily generalizable but one can infer from the clinical significance highlighted which is in keeping with previous studies. The authors identified the convenience sampling methods, small sample size with the lack of a control group and a short study period of one year.

Implications for Nursing: Diabetes care is a complex medical problem that requires close monitoring and the approach to management from a collaborative standpoint. If the patient with type 2 diabetes are seen by the NP on a regular basis with inclusion of a plan of care and is referred as necessary to a collaborative practice team, the chances of better glucose control can be achieved by this approach due to more consistent and specialist monitoring.

Suggested Study:  NP with dual skills and additional responsibilities, in caring for diabetes and their outcome in human health and societal costs and saving.

References

• Parker, R. A., Hook, L. D., Jones, M. E. (2016). Glycemic control: can nurse practitioners on interprofessional collaborative practice team enhance clinical outcomes? American Association of Nurse Practitioners.  (652-658).
• Gray, J.R. (2017). Ethics in Research. The practice of nursing research: Appraisal, synthesis, and generation of evidence. 8th Edition. St Louis, MO: Elsevier. Pp 157-188.
• Grove, S. K. (2017). Sampling. The practice of nursing research: Appraisal, synthesis, and generation of evidence. 8th Edition. St Louis, MO: Elsevier. PP 329-361.
• Sutherland, S. (2017). Quantitative methodology: interventional designs and methods. The practice of nursing research: Appraisal, synthesis, and generation of evidence. 8th Edition. St Louis, MO: Elsevier. PP 217-248